LEIDOS. January 1, BC PPO Plan (non-california resident) Lumenos HSA Benefit Booklet SPD BC PPO HEALTHY FOCUS ADVANTAGE HSA PLAN

Transcription

1 LEIDOS January 1, 2016 BC PPO Plan (non-california resident) Lumenos HSA Benefit Booklet SPD BC PPO HEALTHY FOCUS ADVANTAGE HSA PLAN

2 Dear Plan Member: This Benefit Booklet provides a complete explanation of your benefits, limitations and other plan provisions which apply to you. Subscribers and covered dependents ( members ) are referred to in this booklet as you and your. The plan administrator is referred to as we, us and our. All italicized words have specific definitions. These definitions can be found either in the specific section or in the DEFINITIONS section of this booklet. Please read this Benefit Booklet ( benefit booklet ) carefully so that you understand all the benefits your plan offers. Keep this Benefit Booklet handy in case you have any questions about your coverage. Important: This is not an insured benefit plan. The benefits described in this Benefit Booklet or any rider or amendments hereto are funded by the plan administrator who is responsible for their payment. Anthem Blue Cross Life and Health Insurance Company provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association (BCA).

3 COMPLAINT NOTICE All complaints and disputes relating to coverage under this plan must be resolved in accordance with the plan s grievance procedures. Grievances may be made by telephone (please call the number described on your Identification Card) or in writing (write to Anthem Blue Cross Life and Health Insurance Company, Oxnard Street, Woodland Hills, CA marked to the attention of the Customer Service Department named on your identification card). If you wish, the Claims Administrator will provide a Complaint Form which you may use to explain the matter. All grievances received under the plan will be acknowledged in writing, together with a description of how the plan proposes to resolve the grievance. Grievances that cannot be resolved by this procedure shall be submitted to arbitration.

4 Claims Administered by: ANTHEM BLUE CROSS on behalf of ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY

5 TABLE OF CONTENTS TYPES OF PROVIDERS... 1 SUMMARY OF BENEFITS... 6 MEDICAL BENEFITS... 7 MEDICAL DEDUCTIBLE MEDICAL OUT-OF-POCKET AMOUNTS YOUR MEDICAL BENEFITS MAXIMUM ALLOWED AMOUNT CO-PAYMENTS AND MEDICAL BENEFIT MAXIMUMS CREDITING PRIOR PLAN COVERAGE CONDITIONS OF COVERAGE MEDICAL CARE THAT IS COVERED MEDICAL CARE THAT IS NOT COVERED SUBROGATION AND REIMBURSEMENT COORDINATION OF BENEFITS BENEFITS FOR MEDICARE ELIGIBLE MEMBERS UTILIZATION REVIEW PROGRAM DECISION AND NOTICE REQUIREMENTS HEALTH PLAN INDIVIDUAL CASE MANAGEMENT EXCEPTIONS TO THE UTILIZATION REVIEW PROGRAM QUALITY ASSURANCE HOW COVERAGE BEGINS AND ENDS HOW COVERAGE BEGINS HOW COVERAGE ENDS CONTINUATION OF COVERAGE EXTENSION OF BENEFITS GENERAL PROVISIONS BINDING ARBITRATION DEFINITIONS YOUR RIGHT TO APPEALS FOR YOUR INFORMATION SPD BC PPO HEALTHY FOCUS ADVANTAGE HSA PLAN

6 TYPES OF PROVIDERS PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. THE MEANINGS OF WORDS AND PHRASES IN ITALICS ARE DESCRIBED IN THE SECTION OF THIS BOOKLET ENTITLED DEFINITIONS. Participating Providers. There are two kinds of participating providers in this plan: PPO Providers are providers who participate in a Blue Cross and/or Blue Shield Plan. PPO Providers have agreed to a rate they will accept as reimbursement for covered services that is generally lower than the rate charged by Traditional Providers. Participating providers have agreed to a rate they will accept as reimbursement for covered services. Traditional Providers are providers who might not participate in a Blue Cross and/or Blue Shield Plan, but have agreed to a rate they will accept as reimbursement for covered services for PPO members. The level of benefits paid under this plan is determined as follows: If your plan identification card (ID card) shows a PPO suitcase logo and: You go to a PPO Provider, you will get the higher level of benefits of this plan. You go to a Traditional Provider because there are no PPO Providers in your area, you will get the higher level of benefits of this plan. If your ID card does NOT have a PPO suitcase logo, you must go to a Traditional Provider to get the higher level of benefits of this plan. If you need details about a provider s license or training, or help choosing a physician who is right for you, call the customer service number on the back of your ID card. How to Access Primary and Specialty Care Services Your health plan covers care provided by primary care physicians and specialty care providers. To see a primary care physician, simply visit any participating provider physician who is a general or family practitioner, internist or pediatrician. Your health plan also covers care provided by any participating provider specialty care provider you choose (certain providers services are covered only upon referral of an M.D. 1

7 (medical doctor) or D.O. (doctor of osteopathy), see Physician, below). Referrals are never needed to visit any participating provider specialty care provider including a behavioral health care provider. To make an appointment call your physician s office: Tell them you are a PPO Plan member. Have your Member ID card handy. They may ask you for your group number, member I.D. number, or office visit copay. Tell them the reason for your visit. When you go for your appointment, bring your Member ID card. After hours care is provided by your physician who may have a variety of ways of addressing your needs. Call your physician for instructions on how to receive medical care after their normal business hours, on weekends and holidays. This includes information about how to receive non-emergency care and non-urgent care within the service area for a condition that is not life threatening, but that requires prompt medical attention. If you have an emergency, call 911 or go to the nearest emergency room. Please call the toll-free BlueCard Provider Access number on your ID card to find a participating provider in your area. A directory of PPO Providers is available upon request. Certain categories of providers defined in this benefit booklet as participating providers may not be available in the Blue Cross and/or Blue Shield Plan in the service area where you receive services. See Co-Payments in the SUMMARY OF BENEFITS section and Maximum Allowed Amount in the YOUR MEDICAL BENEFITS section for additional information on how health care services you obtain from such providers are covered. Non-Participating Providers. Non-participating providers are providers which have not agreed to participate in a Blue Cross and/or Blue Shield Plan. They have not agreed to the reimbursement rates and other provisions. The claims administrator has processes to review claims before and after payment to detect fraud, waste, abuse and other inappropriate activity. Members seeking services from non-participating providers could be balance billed by the non-participating provider for those services that are determined to be not payable as a result of these review processes and meets the criteria set forth in any applicable state regulations adopted pursuant to state law. A claim may also be determined to be not payable due to a provider's failure to submit medical records with the claims that are under review in these processes. 2

8 Physicians. "Physician" means more than an M.D. Certain other practitioners are included in this term as it is used throughout the plan. This doesn't mean they can provide every service that a medical doctor could; it just means that the plan will cover expense you incur from them when they're practicing within their specialty the same as if the care were provided by a medical doctor. Other Health Care Providers. Other health care providers are neither physicians nor hospitals. See the definition of "Other Health Care Providers" in the DEFINITIONS section for a complete list of those providers. Other health care providers are not participating providers. Reproductive Health Care Services. Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan and that you or your dependent might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective physician or clinic, or call the customer service telephone number listed on your ID card to ensure that you can obtain the health care services that you need. Centers of Medical Excellence and Blue Distinction Centers. The claims administrator is providing access to Centers of Medical Excellence (CME) network and Blue Distinction Centers for Specialty Care (BDCSC). The facilities included in each of these networks are selected to provide the following specified medical services: Transplant Facilities. Transplant facilities have been organized to provide services for the following specified transplants: heart, liver, lung, combination heart-lung, kidney, pancreas, simultaneous pancreas-kidney, or bone marrow/stem cell and similar procedures. Subject to any applicable co-payments or deductibles, CME and BDCSC have agreed to a rate they will accept as payment in full for covered services. Bariatric Facilities. Hospital facilities have been organized to provide services for bariatric surgical procedures, such as gastric bypass and other surgical procedures for weight loss programs. Care Outside the United States BlueCard Worldwide Prior to travel outside the United States, call the customer service telephone number listed on your ID card to find out if your plan has BlueCard Worldwide benefits. Your coverage outside the United States is limited and the claims administrator recommends: Before you leave home, call the customer service number on your ID card for coverage details. You have coverage for services and 3

9 supplies furnished in connection only with urgent care or an emergency when travelling outside the United States. Always carry your current ID card. In an emergency, seek medical treatment immediately. The BlueCard Worldwide Service Center is available 24 hours a day, seven days a week toll-free at (800) 810-BLUE (2583) or by calling collect at (804) An assistance coordinator, along with a medical professional, will arrange a physician appointment or hospitalization, if needed. Payment Information Participating BlueCard Worldwide hospitals. In most cases, you should not have to pay upfront for inpatient care at participating BlueCard Worldwide hospitals except for the out-of-pocket costs you normally pay (non-covered services, deductible, copays, and coinsurance). The hospital should submit your claim on your behalf. Doctors and/or non-participating hospitals. You will have to pay upfront for outpatient services, care received from a physician, and inpatient care from a hospital that is not a participating BlueCard Worldwide hospital. Then you can complete a BlueCard Worldwide claim form and send it with the original bill(s) to the BlueCard Worldwide Service Center (the address is on the form). Claim Filing Participating BlueCard Worldwide hospitals will file your claim on your behalf. You will have to pay the hospital for the out-ofpocket costs you normally pay. You must file the claim for outpatient and physician care, or inpatient hospital care not provided by a participating BlueCard Worldwide hospital. You will need to pay the health care provider and subsequently send an international claim form with the original bills to the claims administrator. Additional Information About BlueCard Worldwide Claims. You are responsible, at your expense, for obtaining an Englishlanguage translation of foreign country provider claims and medical records. Exchange rates are determined as follows: - For inpatient hospital care, the rate is based on the date of admission. 4

10 - For outpatient and professional services, the rate is based on the date the service is provided. Claim Forms International claim forms are available from the claims administrator, from the BlueCard Worldwide Service Center, or online at: The address for submitting claims is on the form. 5

11 SUMMARY OF BENEFITS THE BENEFITS OF THIS PLAN ARE PROVIDED ONLY FOR SERVICES WHICH ARE CONSIDERED TO BE MEDICALLY NECESSARY. THE FACT THAT A PHYSICIAN PRESCRIBES OR ORDERS THE SERVICE DOES NOT, IN ITSELF, MAKE IT MEDICALLY NECESSARY OR COVERED. This summary provides a brief outline of your benefits. You need to refer to the entire benefit booklet for complete information about the benefits, conditions, limitations and exclusions of your plan. Second Opinions. If you have a question about your condition or about a plan of treatment which your physician has recommended, you may receive a second medical opinion from another physician. This second opinion visit will be provided according to the benefits, limitations, and exclusions of this plan. If you wish to receive a second medical opinion, remember that greater benefits are provided when you choose a participating provider. You may also ask your physician to refer you to a participating provider to receive a second opinion. After Hours Care. After hours care is provided by your physician who may have a variety of ways of addressing your needs. You should call your physician for instructions on how to receive medical care after their normal business hours, on weekends and holidays, or to receive nonemergency care and non-urgent care within the service area for a condition that is not life threatening but that requires prompt medical attention. If you have an emergency, call 911 or go to the nearest emergency room. Telehealth. This plan provides benefits for covered services that are appropriately provided through telehealth, subject to the terms and conditions of the plan. In-person contact between a health care provider and the patient is not required for these services, and the type of setting where these services are provided is not limited. Telehealth is the means of providing health care services using information and communication technologies in the consultation, diagnosis, treatment, education, and management of the patient s health care when the patient is located at a distance from the health care provider. Telehealth does not include consultations between the patient and the health care provider, or between health care providers, by telephone, facsimile machine, or electronic mail. All benefits are subject to coordination with benefits under certain other plans. The benefits of this plan may be subject to the SUBROGATION AND REIMBURSEMENT section. 6

12 IMPORTANT: For the full benefits of this plan to be payable, each time you are admitted to a hospital, residential treatment center, skilled nursing facility or transplant facility, receive services from a home health agency, hospice unit or home infusion therapy provider, the appropriate utilization reviews must be performed. When pre-service review is not performed as required, the benefits to which a member would be otherwise entitled may be subject to a 20% reduction. (See UTILIZATION REVIEW PROGRAM for information on how to obtain certification.) DEDUCTIBLES Calendar Year Deductibles Member Deductibles: MEDICAL BENEFITS Participating providers and other health care providers... $1,300 Non-participating providers... $1,300 Family Deductible: Participating providers and other health care providers... $2,600 Non-participating providers... $2,600 Exceptions: In certain circumstances, the Calendar Year Deductibles may not apply, as described below: The Calendar Year Deductible will not apply to benefits for Preventive Care Services provided by a participating provider. The Calendar Year Deductible will not apply to covered charges for prenatal care services provided by a participating provider who is not a specialist. Note: This exception only applies to the charge for the visit itself. It does not apply to any other charges made during that visit, such as for testing procedures, surgery, etc. 7

13 CO-PAYMENTS Co-Payments.* After you have met your Calendar Year Deductible, you will be responsible for the following percentages of the maximum allowed amount: Participating Providers... 20% Other Health Care Providers... 20% Non-Participating Providers... 50% Note: In addition to the Co-Payment shown above, you will be required to pay any amount in excess of the maximum allowed amount for the services of an other health care provider or non-participating provider. *Exceptions: There will be no Co-Payment for any covered services provided by a participating provider under the Preventive Care benefit. You will not be required to pay a Co-Payment for prenatal care services provided by a participating provider who is not a specialist. Note: This exception only applies to the charge for the visit itself. It does not apply to any other charges made during that visit, such as for testing procedures, surgery, etc. Your Co-Payment for non-participating providers will be the same as for participating providers for the following services. You may be responsible for charges which exceed the maximum allowed amount. a. All emergency services; b. An authorized referral from the claims administrator to a nonparticipating provider; c. Charges by a type of physician not represented in a Blue Cross and/or Blue Shield Plan; or d. Clinical Trials. If you receive services from a category of provider defined in this benefit booklet as an other health care provider but such a provider participates in the Blue Cross and/or Blue Shield Plan in that service area, your Co-Payment will be as follows: a. if you go to a participating provider, your Co-payment will be the same as for participating providers. 8

14 b. if you go to a non-participating provider, your Co-Payment will be the same as for non-participating providers. If you receive services from a category of provider defined in this benefit booklet as a participating provider that is not available in the Blue Cross and/or Blue Shield Plan in that service area, your Co-Payment will be the same as for participating providers. Your Co-Payment for ambulance transportation or for services provided in a hospital emergency room, including the services of a physician, will be the same as for non-participating providers when the treatment is not a true medical emergency. Your Co-Payment for specified transplants (heart, liver, lung, combination heart-lung, kidney, pancreas, simultaneous pancreas-kidney, or bone marrow/stem cell and similar procedures) determined to be medically necessary and performed at a designated CME or BDCSC will be the same as for participating providers. See UTILIZATION REVIEW PROGRAM. Your Co-Payment for bariatric surgical procedures determined to be medically necessary and performed at a designated BDCSC will be the same as for participating providers. See UTILIZATION REVIEW PROGRAM. Out-of-Pocket Amount*. After you have made the following total out-ofpocket payments for covered services or supplies during a calendar year, you will no longer be required to pay a Co-Payment for the remainder of that year, but you remain responsible for costs in excess of the maximum allowed amount. Per member Participating providers and other health care providers... $3,000 Non-participating providers... $3,000 Per family Participating providers and other health care providers... $6,000** Non-participating providers... $6,000** *Exception: Expense which is applied toward Medical Management Program Penalty, which is incurred for non-covered services or supplies, or which is in excess of the amount of the maximum allowed amount, 9

15 will not be applied toward your Out-of-Pocket Amount, and is always your responsibility. Medical Management Program Penalties. The maximum allowed amount may be reduced by 20% for the following: Covered hospital, residential treatment center, skilled nursing facility or transplant facility expenses when pre-service review is not obtained as required for admission. See UTILIZATION REVIEW PROGRAM. Covered home health care services, home infusion therapy services or hospice care when pre-service review is not obtained as required for treatment. See UTILIZATION REVIEW PROGRAM. MEDICAL BENEFIT MAXIMUMS The plan will pay benefits, for the following services and supplies, up to the maximum amounts, or for the maximum number of dollar amounts, days and visits shown below: Skilled Nursing Facility For covered skilled nursing facility care days* per confinement * The 60 day limit will be counted against the maximum limit for home health care services. Home Health Care For covered home health services visits* per calendar year * Includes skilled nursing facility care and private duty nursing services. Infertility Services For all covered services and supplies except, artificial insemination... $5,000 during your lifetime Physical Therapy, Physical Medicine, Occupational Therapy, Speech Therapy and Chiropractic Services For covered outpatient services except, chiropractic services visits per calendar year 10

16 Transplant Travel Expense For hotel accommodations... $50 per day for each person For all authorized travel expense in connection with a specified transplant... $10,000 per transplant Lifetime Maximum For all medical benefits... Unlimited 11

17 MEDICAL DEDUCTIBLE Calendar Year Deductibles. Each year, you will be responsible for satisfying the member s Calendar Year Deductible before the plan begins to pay medical benefits. If members of an enrolled family pay deductible expense in a year equal to the Family Deductible, the Calendar Year Deductible for all family members will be considered to have been met. Participating Providers, CMEs and Other Health Care Providers. Only covered charges up to the maximum allowed amount for the services of participating providers, CMEs and other health care providers will be applied to the participating provider and other health care provider Calendar Year Deductibles. When these deductibles are met, the plan will pay benefits only for the services of participating providers, CMEs and other health care providers. The plan will not pay any benefits for non-participating providers unless the separate non-participating provider Calendar Year Deductibles (as applicable) are met. Non-Participating Providers. Only covered charges up to the maximum allowed amount for the services of non-participating providers will be applied to the non-participating provider Calendar Year Deductibles. The plan will pay benefits for the services of nonparticipating providers only when the applicable non-participating provider deductibles are met. Prior Plan Calendar Year Deductibles. If you were covered under the prior plan any amount paid during the same calendar year toward your calendar year deductible under the prior plan, will be applied toward your Calendar Year Deductible under this plan; provided that, such payments were for charges that would be covered under this plan. MEDICAL OUT-OF-POCKET AMOUNTS Satisfaction of the Out-of-Pocket Amount*. If, after you have met your Calendar Year Deductible, you pay Co-Payments equal to your Outof-Pocket Amount per member during a calendar year, you will no longer be required to make Co-Payments for any covered services or supplies during the remainder of that year. Covered charges applied to your Calendar Year Deductible will be applied to both the participating provider and other health care provider Out-of-Pocket Amount and the non-participating provider Out-of-Pocket Amount no matter where such charges are incurred. Participating Providers, CMEs, BDCSCs and Other Health Care Providers. Only covered charges up to the maximum allowed amount for the services of a participating provider, CME, BDCSC or other health care provider will be applied to the participating provider and other health care provider Out-of-Pocket Amount. 12

18 After this Out-of-Pocket Amount has been satisfied during a benefit year, you will no longer be required to make any Co-Payment for the covered services provided by a participating provider, CME, BDCSC or other health care provider for the remainder of that year. Non-Participating Providers. Only covered charges up to the maximum allowed amount for the services of a non-participating provider will be applied to the non-participating provider Out-of-Pocket Amount. After this Out-of-Pocket Amount has been satisfied during a benefit year, you will no longer be required to make any Co-Payment for the covered services provided by a non-participating provider for the remainder of that year. Family Maximum Out-of-Pocket Amount*. When the subscriber and one or more members of the subscriber s family are insured under this plan, if members of an insured family satisfy the Family Out-of-Pocket Amount during a calendar year, no further Out-of-Pocket Amount will be required for any insured member of that family for expenses incurred during that year. Charges Which Do Not Apply Toward the Out-of-Pocket Amount. Charges for services or supplies not covered under this plan, charges which are applied toward Medical Management Program Penalty and charges which exceed the maximum allowed will not be applied toward satisfaction of an Out-of-Pocket Amount. General YOUR MEDICAL BENEFITS MAXIMUM ALLOWED AMOUNT This section describes the term maximum allowed amount as used in this benefit booklet, and what the term means to you when obtaining covered services under this plan. The maximum allowed amount is the total reimbursement payable under your plan for covered services you receive from participating and non-participating providers. It is the plan s payment towards the services billed by your provider combined with any Deductible or Co-Payment owed by you. In some cases, you may be required to pay the entire maximum allowed amount. For instance, if you have not met your Deductible under this plan, then you could be responsible for paying the entire maximum allowed amount for covered services. In addition, if these services are received from a nonparticipating provider, you may be billed by the provider for the difference between their charges and the maximum allowed amount. In many situations, this difference could be significant. Below are two examples that illustrate how the maximum allowed amount works. These examples are for illustration purposes only. 13

19 Example: The plan has a member Co-Payment of 30% for participating provider services after the Deductible has been met. The member receives services from a participating surgeon. The charge is $2,000. The maximum allowed amount under the plan for the surgery is $1,000. The member s Co-Payment responsibility when a participating surgeon is used is 30% of $1,000, or $300. This is what the member pays. The plan pays 70% of $1,000, or $700. The participating surgeon accepts the total of $1,000 as reimbursement for the surgery regardless of the charges. Example: The plan has a member Co-Payment of 50% for nonparticipating provider services after the Deductible has been met. The member receives services from a non-participating surgeon. The charge is $2,000. The maximum allowed amount under the plan for the surgery is $1,000. The member s Co-Payment responsibility when a non-participating surgeon is used is 50% of $1,000, or $500. The plan pays the remaining 50% of $1,000, or $500. In addition, the non-participating surgeon could bill the member the difference between $2,000 and $1,000. So the member s total out-of-pocket charge would be $500 plus an additional $1,000, for a total of $1,500. When you receive covered services, the claims administrator will, to the extent applicable, apply claim processing rules to the claim submitted. The claims administrator uses these rules to evaluate the claim information and determine the accuracy and appropriateness of the procedure and diagnosis codes included in the submitted claim. Applying these rules may affect the maximum allowed amount if the claims administrator determines that the procedure and/or diagnosis codes used were inconsistent with procedure coding rules and/or reimbursement policies. For example, if your provider submits a claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed, the maximum allowed amount will be based on the single procedure code. Provider Network Status The maximum allowed amount may vary depending upon whether the provider is a participating provider, a non-participating provider or other health care provider. Participating Providers. For covered services performed by a participating provider the maximum allowed amount for this plan will be the rate the participating provider has agreed with the claims administrator to accept as reimbursement for the covered services. Because participating providers have agreed to accept the maximum allowed amount as payment in full for those covered services, they 14

20 should not send you a bill or collect for amounts above the maximum allowed amount. However, you may receive a bill or be asked to pay all or a portion of the maximum allowed amount to the extent you have not met your Deductible or have a Co-Payment. Please call the customer service telephone number on your ID card for help in finding a participating provider or visit If you go to a hospital which is a participating provider, you should not assume all providers in that hospital are also participating providers. To receive the greater benefits afforded when covered services are provided by a participating provider, you should request that all your provider services (such as services by an anesthesiologist) be performed by participating providers whenever you enter a hospital. If you are planning to have outpatient surgery, you should first find out if the facility where the surgery is to be performed is an ambulatory surgical center. An ambulatory surgical center is licensed as a separate facility even though it may be located on the same grounds as a hospital (although this is not always the case). If the center is licensed separately, you should find out if the facility is a participating provider before undergoing the surgery. Note: If an other health care provider is participating in a Blue Cross and/or Blue Shield Plan at the time you receive services, such provider will be considered a participating provider for the purposes of determining the maximum allowed amount. If a provider defined in this benefit booklet as a participating provider is of a type not represented in the local Blue Cross and/or Blue Shield Plan at the time you receive services, such provider will be considered a nonparticipating provider for the purposes of determining the maximum allowed amount. Non-Participating Providers and Other Health Care Providers.* Providers who are not in the Prudent Buyer network are non-participating providers or other health care providers, subject to Blue Cross Blue Shield Association rules governing claims filed by certain ancillary providers. For covered services you receive from a non-participating provider or other health care provider, the maximum allowed amount will be based on the claims administrator s applicable non-participating provider rate or fee schedule for this plan, an amount negotiated by the claims administrator or a third party vendor which has been agreed to by the non-participating provider, an amount derived from the total charges billed by the non-participating provider, or an amount based on information provided by a third party vendor, or an amount based on reimbursement or cost information from the Centers for Medicare and Medicaid Services ( CMS ). When basing the maximum allowed amount upon the level or method of reimbursement used by CMS, the claims 15

21 administrator will update such information, which is unadjusted for geographic locality, no less than annually. Providers who are not contracted for this product, but are contracted for other products, are also considered non-participating providers. For this plan, the maximum allowed amount for services from these providers will be one of the methods shown above unless the provider s contract specifies a different amount. Unlike participating providers, non-participating providers and other health care providers may send you a bill and collect for the amount of the non-participating provider s or other health care provider s charge that exceeds the maximum allowed amount under this plan. You may be responsible for paying the difference between the maximum allowed amount and the amount the non-participating provider or other health care provider charges. This amount can be significant. Choosing a participating provider will likely result in lower out of pocket costs to you. Please call the customer service number on your ID card for help in finding a participating provider or visit the claims administrator s website at Customer service is also available to assist you in determining this plan s maximum allowed amount for a particular covered service from a non-participating provider or other health care provider. Please see the Inter-Plan Programs in the section entitled GENERAL PROVISIONS for additional information. *Exceptions: Clinical Trials. The maximum allowed amount for services and supplies provided in connection with Clinical Trials will be the lesser of the billed charge or the amount that ordinarily applies when services are provided by a participating provider. If Medicare is the primary payor, the maximum allowed amount does not include any charge: 1. By a hospital, in excess of the approved amount as determined by Medicare; or 2. By a physician who is a participating provider who accepts Medicare assignment, in excess of the approved amount as determined by Medicare; or 3. By a physician who is a non-participating provider or other health care provider who accepts Medicare assignment, in excess of the lesser of maximum allowed amount stated above, or the approved amount as determined by Medicare; or 16

22 4. By a physician or other health care provider who does not accept Medicare assignment, in excess of the lesser of the maximum allowed amount stated above, or the limiting charge as determined by Medicare. You will always be responsible for expense incurred which is not covered under this plan. WARNING! The Maximum Allowed Amount may be reduced by 20% for the following: 1. Covered hospital, residential treatment center, skilled nursing facility or transplant facility expenses when pre-service review is not obtained as required for admission. See UTILIZATION REVIEW PROGRAM. 2. Covered home health care services, home infusion therapy services or hospice care when pre-service review is not obtained as required for treatment. See UTILIZATION REVIEW PROGRAM. COST SHARE For certain covered services, and depending on your plan design, you may be required to pay all or a part of the maximum allowed amount as your cost share amount (Deductibles or Co-Payments). Your cost share amount and the Out-Of-Pocket Amounts may be different depending on whether you received covered services from a participating provider or non-participating provider. Specifically, you may be required to pay higher cost-sharing amounts or may have limits on your benefits when using non-participating providers. Please see the SUMMARY OF BENEFITS section for your cost share responsibilities and limitations, or call the customer service telephone number on your ID card to learn how this plan s benefits or cost share amount may vary by the type of provider you use. The plan will not provide any reimbursement for non-covered services. You may be responsible for the total amount billed by your provider for non-covered services, regardless of whether such services are performed by a participating provider or non-participating provider. Noncovered services include services specifically excluded from coverage by the terms of your plan and services received after benefits have been exhausted. Benefits may be exhausted by exceeding, for example, Medical Benefit Maximums or day/visit limits. In some instances you may only be asked to pay the lower participating provider cost share percentage when you use a non-participating provider. For example, if you go to a participating hospital or facility and receive covered services from a non-participating provider such as a radiologist, anesthesiologist or pathologist providing services at the 17

23 hospital or facility, you will pay the participating provider cost share percentage of the maximum allowed amount for those covered services. However, you also may be liable for the difference between the maximum allowed amount and the non-participating provider s charge. AUTHORIZED REFERRALS In some circumstances the claims administrator may authorize participating provider cost share amounts (Deductibles or Co-Payments) to apply to a claim for a covered service you receive from a nonparticipating provider. In such circumstance, you or your physician must contact the claims administrator in advance of obtaining the covered service. It is your responsibility to ensure that the claims administrator has been contacted. If the claims administrator authorizes a participating provider cost share amount to apply to a covered service received from a non-participating provider, you also may still be liable for the difference between the maximum allowed amount and the non-participating provider s charge. Please call the customer service telephone number on your ID card for authorized referral information or to request authorization. CO-PAYMENTS AND MEDICAL BENEFIT MAXIMUMS After you satisfy your Medical Deductible, your Co-Payment will be subtracted and benefits will be paid up to the maximum allowed amount, not to exceed any applicable Medical Benefit Maximum. The Co- Payments and Medical Benefit Maximums are set forth in the SUMMARY OF BENEFITS. CO-PAYMENTS After you have satisfied any applicable deductible, your Co-Payment will be subtracted from the maximum allowed amount remaining. If your Co-Payment is a percentage, the applicable percentage will be applied to the maximum allowed amount remaining after any deductible has been met. This will determine the dollar amount of your Co- Payment. MEDICAL BENEFIT MAXIMUMS The plan does not make benefit payments for any member in excess of any of the Medical Benefit Maximums. Prior Plan Maximum Benefits. If you were covered under the prior plan, any benefits paid to you under the prior plan will reduce any maximum amounts you are eligible for under this plan which apply to the same benefit. 18

24 CREDITING PRIOR PLAN COVERAGE If you were covered by the plan administrator s prior plan immediately before the plan administrator signs up with the claims administrator, with no lapse in coverage, then you will get credit for any accrued Calendar Year Deductible and, if applicable and approved by the claims administrator, Out of Pocket Amounts under the prior plan. This does not apply to individuals who were not covered by the prior plan on the day before the plan administrator s coverage with the claims administrator began, or who join the plan administrator later. If the plan administrator moves from one of the claims administrator s plans to another, (for example, changes its coverage from HMO to PPO), and you were covered by the other product immediately before enrolling in this product with no break in coverage, then you may get credit for any accrued Calendar Year Deductible and Out of Pocket Amounts, if applicable and approved by the claims administrator. Any maximums, when applicable, will be carried over and charged against the Medical Benefit Maximums under this plan. If the plan administrator offers more than one of the claims administrator s products, and you change from one product to another with no break in coverage, you will get credit for any accrued Calendar Year Deductible and, if applicable, Out of Pocket Amounts and any maximums will be carried over and charged against Medical Benefit Maximums under this plan. If the plan administrator offers coverage through other products or carriers in addition to the claims administrator s, and you change products or carriers to enroll in this product with no break in coverage, you will get credit for any accrued Calendar Year Deductible, Out of Pocket Amount, and any Medical Benefit Maximums under this plan. This Section Does Not Apply To You If: The plan administrator moves to this plan at the beginning of a calendar year; You change from one of the claims administrator s individual policies to the plan administrator s plan; You change employers; or You are a new member of the plan administrator who joins after the plan administrator's initial enrollment with the claims administrator. 19

25 CONDITIONS OF COVERAGE The following conditions of coverage must be met for expense incurred for services or supplies to be covered under this plan. 1. You must incur this expense while you are covered under this plan. Expense is incurred on the date you receive the service or supply for which the charge is made. 2. The expense must be for a medical service or supply furnished to you as a result of illness or injury or pregnancy, unless a specific exception is made. 3. The expense must be for a medical service or supply included in MEDICAL CARE THAT IS COVERED. Additional limits on covered charges are included under specific benefits and in the SUMMARY OF BENEFITS. 4. The expense must not be for a medical service or supply listed in MEDICAL CARE THAT IS NOT COVERED. If the service or supply is partially excluded, then only that portion which is not excluded will be covered under this plan. 5. The expense must not exceed any of the maximum benefits or limitations of this plan. 6. Any services received must be those which are regularly provided and billed by the provider. In addition, those services must be consistent with the illness, injury, degree of disability and your medical needs. Benefits are provided only for the number of days required to treat your illness or injury. 7. All services and supplies must be ordered by a physician. MEDICAL CARE THAT IS COVERED Subject to the Medical Benefit Maximums in the SUMMARY OF BENEFITS, the requirements set forth under CONDITIONS OF COVERAGE and the exclusions or limitations listed under MEDICAL CARE THAT IS NOT COVERED, benefits will be provided for the following services and supplies: Urgent Care. Services and supplies received to prevent serious deterioration of your health or, in the case of pregnancy, the health of the unborn child, resulting from an unforeseen illness, medical condition, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed. Urgent care services are not emergency services. Services for urgent care are typically provided by an urgent care center or other facility such as a physician s office. Urgent care can be obtained from participating providers or non-participating providers. 20

26 Hospital 1. Inpatient services and supplies, provided by a hospital. The maximum allowed amount will not include charges in excess of the hospital s prevailing two-bed room rate unless your physician orders, and the claims administrator authorizes, a private room as medically necessary. 2. Services in special care units. 3. Outpatient services and supplies provided by a hospital, including outpatient surgery. Hospital services are subject to pre-service review to determine medical necessity. Please refer to UTILIZATION REVIEW PROGRAM for information on how to obtain the proper reviews. Hospital Pre-Admission Testing. Outpatient hospital services for preadmission testing if the tests are: 1. Made within five days prior to the date inpatient care begins; 2. Made in the same hospital where the inpatient care is scheduled; 3. Ordered by the same physician who ordered the inpatient care; and 4. The same as would have been made as an inpatient, or admission is not appropriate or medically necessary. Skilled Nursing Facility. Inpatient services and supplies provided by a skilled nursing facility, for up to 60 days per confinement. The amount by which your room charge exceeds the prevailing two-bed room rate of the skilled nursing facility is not considered covered under this plan. Skilled nursing facility services and supplies are subject to pre-service review to determine medical necessity. Please refer to UTILIZATION REVIEW PROGRAM for information on how to obtain the proper reviews. Note: Services provided by a skilled nursing facility will be counted against both this 60 day limit and the 100 visit limit applicable to benefits for services provided by a home health agency. If covered charges are applied toward the Calendar Year Deductible and payment is not provided, those days will be included in the 60 days for that year. Private Duty Nursing. Services of a licensed nurse (R.N., L.P.N. or L.V.N.) for nursing services. The plan s maximum payment for private duty nursing and home health care services is limited to a combined total of 100 visits per calendar year. Private duty means a session of four or more hours that continuous nursing care is furnished to you alone. 21

27 The combined maximum for home health care and private duty nursing services will be 100 visits during a calendar year. In addition, the maximum for home health care services will be further reduced by any skilled nursing care paid to you or on your behalf under any other health plan sponsored by the plan administrator. If covered charges are applied toward the Calendar Year Deductible and payment is not provided, those visits will be included in the 100 visits for that year. Home Health Care. The following services provided by a home health agency: 1. Services of a registered nurse or licensed vocational nurse under the supervision of a registered nurse or a physician. 2. Services of a licensed therapist for physical therapy, occupational therapy, speech therapy, or respiratory therapy. 3. Services of a medical social service worker. 4. Services of a health aide who is employed by (or who contracts with) a home health agency. Services must be ordered and supervised by a registered nurse employed by the home health agency as professional coordinator. These services are covered only if you are also receiving the services listed in 1 or 2 above. 5. Medically necessary supplies provided by the home health agency. The combined maximum for home health care and private duty nursing services will be 100 visits during a calendar year. In addition, the maximum for home health care services will be further reduced by any skilled nursing care paid to you or on your behalf under any other health plan sponsored by the plan administrator. A visit of four hours or less by a home health aide shall be considered as one home health visit. If covered charges are applied toward the Calendar Year Deductible and payment is not provided, those visits will be included in the 100 visits for that year. Home health care services are subject to pre-service review to determine medical necessity. Please refer to UTILIZATION REVIEW PROGRAM for information on how to obtain the proper reviews. Home health care services are not covered if received while you are receiving benefits under the "Hospice Care" provision of this section. Hospice Care. The services and supplies listed below are covered when provided by a hospice for the palliative treatment of pain and other symptoms associated with a terminal disease. Palliative care is care that controls pain and relieves symptoms but is not intended to cure the 22

28 illness. You must be suffering from a terminal illness for which the prognosis of life expectancy is one year or less, as certified by your physician and submitted to the claims administrator. Covered services are available on a 24-hour basis for the management of your condition. 1. Interdisciplinary team care with the development and maintenance of an appropriate plan of care. 2. Short-term inpatient hospital care when required in periods of crisis or as respite care. Coverage of inpatient respite care is provided on an occasional basis and is limited to a maximum of five consecutive days per admission. 3. Skilled nursing services provided by or under the supervision of a registered nurse. Certified home health aide services and homemaker services provided under the supervision of a registered nurse. 4. Social services and counseling services provided by a qualified social worker. 5. Dietary and nutritional guidance. Nutritional support such as intravenous feeding or hyperalimentation. 6. Physical therapy, occupational therapy, speech therapy, and respiratory therapy provided by a licensed therapist. 7. Volunteer services provided by trained hospice volunteers under the direction of a hospice staff member. 8. Pharmaceuticals, medical equipment, and supplies necessary for the management of your condition. Oxygen and related respiratory therapy supplies. 9. Bereavement services, including assessment of the needs of the bereaved family and development of a care plan to meet those needs, both prior to and following the subscriber s or the dependent s death. Bereavement services are available to surviving members of the immediate family for a period of one year after the death. Your immediate family means your spouse, children, step-children, parents, and siblings. 10. Palliative care (care which controls pain and relieves symptoms, but does not cure) which is appropriate for the illness. Your physician must consent to your care by the hospice and must be consulted in the development of your treatment plan. The hospice must submit a written treatment plan to the claims administrator every 30 days. 23